Posted by: Nicholas Ramscar10 December 2012
Recently, I read once again that a large proportion of our time is taken up with 'minor illness'. The exact percentage always varies, but the underlying message is consistent – a lot of what we do is dross, and could be done better by someone cheaper who can follow a protocol.
The response to this, and to the ongoing erosion of general practice, is so glaringly obvious that I think we need to trumpet it whenever we can. Anti-emetics at the ready, because this is going to sound trite, but I believe my next sentence is true, and should be carved above the door at the Department of Health. Nobody consults a doctor for a problem they know is not serious.
The 26-year-old with mild gastroenteritis hasn’t crossed town because he fancied wasting somebody’s time; he’s there because someone he knows has pancreatic cancer. The 18-year-old with the most benign mole you’ve ever seen is there because moles and melanoma are always jumbled together in the results of an internet search.
The single mum with back pain is there because kids don’t come with instructions, she’s running out of money, the father’s left again, and she doesn’t have anywhere else to go where an adult will sit with her in a quiet room and talk. Even the perennial favourite of the media, the completely well adult with a cold, is there because she believes these things can develop into pneumonia if left untreated. And somebody she knew once died of pneumonia.
People who are scared are vulnerable, and their fear is liable to make rational thought difficult. When we are able to do our job properly, and spend time with our patients, we are uniquely placed to put these fears in perspective and dissipate them early on.
If we are able to listen, to perhaps shoulder a little responsibility, and not to cover our backs with over-investigation that reinforces anxieties, we can do tremendous good.
A large part of the magic of a working relationship between doctor and patient in general practice has nothing to do with pure medical knowledge, of the kind that can be distilled into a protocol or a flowchart. Our patients don’t need us for this kind of information, which they can get for themselves in gigabytes at the click of a mouse. The added value a GP provides, and the cornerstone of our purpose as a profession, is applying an effective filter - borne of objective experience - to that tide of information.
Once again, and with no apologies for repetition: every patient we see has come with a problem that they believe to be serious enough to warrant attention. Often we may know enough, and be able to apply enough objectivity, to satisfy our patients and ourselves that there is no need for pills or procedures.
If this is done well, it represents the very opposite of a failure or waste of time. If, at the end of a consultation, you have converted a prowling tiger into a trick of the light, you have done a wonderful job for your patient and the health service.
The consultations where 'nothing happened' - no medicines were dispensed, no procedures ordered – are some of the most important.
Failure to appreciate this, to further hobble GPs’ professional freedom or replace us with risk-averse protocols, on the basis that x% of our consultations turned out to be for 'minor illness', betrays a deadly misunderstanding of what general practice is for. Continuing restriction of our ability to use professional judgment will lead to unrelenting escalation of costs, patient anxiety, over-investigation, and iatrogenic harm, and it will be the undoing of the NHS.
Dr Nick Ramscar is a GP in Bracknell, Berkshire